Search Results (70)

Objective: This study aimed to evaluate clinical and radiological outcomes of Ascyrus Medical Dissection Stent (AMDS^®, Artivion Inc.) for acute type A aortic dissection (ATAAD). Methods: Between January 2021 and January 2025, all consecutive patients undergoing emergent surgery for ATAAD and hybrid aortic arch repair using the AMDS from two centers were retrospectively analyzed. Demographic, intraoperative, and postoperative data were collected. Patients were stratified based on 30-day or in-hospital mortality. Survival analysis was performed for patients who survived hospital discharge. Radiological evaluation focused on the presence of distal anastomotic new entries (DANEs), false lumen thrombosis, and aortic remodeling on follow-up computed tomography angiography. A total of 46 patients (12 female, mean age 66.1 ± 13.8 years) were included in the study. Results: The 30-day or in-hospital mortality rate was 21.7% (10 patients). There were no significant differences in demographic variables between survivors and non-survivors. All patients underwent hemiarch replacement with AMDS stent placement, with 54.3% also requiring aortic root replacement. Median cross-clamp time, hypothermic circulatory arrest (HCA) time, and time of antegrade selective cerebral perfusion did not differ significantly between the two groups. However, significant differences were observed in median cardiopulmonary bypass (CPB) time (151 vs. 274 min, p = 0.02) and HCA temperature (27 °C vs. 25 °C, p = 0.021). Postoperatively, the non-survivor group showed a significantly higher incidence of dialysis requirement (7.7% vs. 60.0%, p = 0.02), use of mechanical circulatory support (3.9% vs. 44.4%, p = 0.01), and re-exploration for bleeding (15.4% vs. 66.7%, p = 0.023). Conclusions: The AMDS^® is an effective adjunct in hemiarch replacement for ATAAD. Moderate hypothermia and optimized perfusion were linked to better early survival, while the device reliably promoted true-lumen expansion with few DANEs. Its rapid deployment may further facilitate the use of moderate hypothermia by balancing procedural efficiency with systemic protection. Full article

Background: Patients presented for complicated redo surgery after previous aortic valve replacement with the indication for aortic root repair due to dilatation or aneurysm. In those cases where the prosthetic aortic valve is in good condition, a valve-sparing procedure might simplify the complicated surgery. The aim of this case series paper is to describe a technique and to show the results of repairing the aortic root without compromising the previously inserted, well-functioning mechanical aortic valve. Methods: Between March 2017 and May 2017, 11 patients underwent re-sternotomy with placement on cardiopulmonary bypass with cardiac arrest and exposure of the aortic root. After the aortotomy, the aortic valve was inspected. Subsequently, the aortic sinuses were resected, sparing the coronary ostia buttons. A prosthetic tube was implanted above the preexisting valve. Finally, the coronary ostia were reattached to the tube, turning this procedure into a complete Bentall. Results: Echocardiography demonstrated fully functional valves and well-implanted aortic prosthesis. All patients were discharged within ten days post-surgery without any adverse events. Conclusions: The delayed two-stage Bentall procedure is a feasible and safe technique that preserves pre-implanted valves and does not cause any distortion of the aortic annulus. Full article

Contemporary evaluation and surgical approaches in congenital aortic valve disease have yielded limited success. The ability to evaluate and understand detailed flow characteristics surrounding surgical repair may be beneficial. This study explores the feasibility and utility of echocardiographic-based blood speckle imaging (BSI) in assessing pre- and post-operative flow characteristics in those with non-stenotic congenital aortic root disease undergoing aortic valve repair or valve-sparing root replacement (VSRR) surgery. Transesophageal echocardiogram was performed during the pre-operative and post-operative assessment surrounding aortic surgery for ten patients with non-stenotic congenital aortic root disease. BSI, utilizing block-matching algorithms, enabled detailed visualization and quantification of flow parameters from the echocardiographic data. Post-operative BSI unveiled enhanced hemodynamic patterns, characterized by quantified changes suggestive of the absence of stenosis and no more than trivial regurgitation. Rectification of an asymmetric jet and the reversal of flow on the posterior aspect of the ascending aorta resulted in a reduced oscillatory shear index ($OSI$) of $0.0543\pm 0.0207$ (pre-op) vs. $0.0275\pm 0.0159$ (post-op) and $p=0.0044$, increased peak wall shear stress of $1.9423\pm 0.6974$ (pre-op) vs. $3.6956\pm 1.4934$ (post-op) and $p=0.0035$, and increased time-averaged wall shear stress of $0.6885\pm 0.8004$ (pre-op) vs. $0.8312\pm 0.303$ (post-op) and $p=0.23$. This correction potentially attenuates cellular alterations within the endothelium. This study demonstrates that children and young adults with non-stenotic congenital aortic root disease undergoing valve-preserving operations experience significant improvements in flow dynamics within the left ventricular outflow tract and aortic root, accompanied by a reduction in $OSI$. These hemodynamic enhancements extend beyond the conventional echocardiographic assessments, offering immediate and valuable insights into the efficacy of surgical interventions. Full article

Background: Infective endocarditis after transcatheter aortic valve replacement (TAVR-IE) is a rare but severe complication associated with high morbidity and mortality. The optimal treatment strategy—surgical explantation versus medical therapy—remains uncertain, particularly given the technical demands of TAVR removal and the advanced age of many affected patients. Methods: We conducted a systematic review and meta-analysis of studies comparing the surgical and medical management of TAVR-IE. Primary outcomes included 30-day mortality and 1-year survival. Secondary analyses explored microbiological profiles, patient demographics, prosthesis type, postoperative complications, and surgical indications. A qualitative synthesis of surgical explantation techniques and reconstructive strategies was also performed based on recent consensus recommendations. Results: Three studies comprising 1557 patients with TAVR-IE were included; 155 (10.0%) underwent surgical treatment. Thirty-day mortality was comparable between groups (surgical: 9.7%; medical: 8.4%), while the pooled odds ratio for one-year survival did not reach statistical significance (OR: 1.91, 95% CI: 0.36–10.22; I² = 88%). However, single-center outcomes demonstrated markedly improved survival with surgery (96% vs. 51%). The most common surgical indications included severe valvular dysfunction (50.3%), aortic root abscess (26.5%), and large vegetations (21.3%), in line with current guideline recommendations. Postoperative complications included acute renal failure (10%) and longer hospitalizations (19.8 vs. 18 days), although these were not statistically different. Contemporary explant strategies—such as the Double Kocher, Tourniquet, and Y-incision aortic enlargement techniques—were highlighted as critical tools for surgical success. Conclusions: While underutilized, surgical intervention for TAVR-IE may offer significant survival benefits in select patients, particularly when guided by established indications and performed at high-volume centers. Outcomes depend heavily on timing, surgical expertise, and appropriate patient selection. As TAVR expands to younger populations, TAVR-IE will become increasingly relevant, necessitating early multidisciplinary involvement and broader familiarity with advanced explant techniques among cardiac surgeons. Full article

Background: Non-adjustable patient characteristics such as diabetes mellitus may influence surgical decision-making and outcome after acute type A aortic dissection (ATAAD). The aim of this study was to compare the degree of aortic wall atherosclerosis and surgical solutions in patients with diabetes mellitus versus those without during ATAAD. Methods: Altogether, 123 consecutive patients undergoing surgery for ATAAD at Tampere University Heart Hospital were evaluated. The ascending aortic wall resected in surgery was processed for histopathological analysis of atherosclerosis, inflammation, and medial layer degeneration. Patients with and without diabetes mellitus were compared during a mean 4.7-year follow-up. Results: There were 11 patients with diabetes mellitus and 112 without. The mean age for all patients was 63.6 years (standard deviation [SD] 13.3). Altogether, 48 patients had a conduit aortic prosthesis replacing the aortic root together with the ascending aorta, including only one patient with diabetes (p = 0.049). Nine patients received a frozen elephant trunk prosthesis to treat the aortic arch together with the ascending aorta. The severity of ascending aorta atherosclerosis was more prominent in patients with diabetes mellitus as compared to patients without (0.8 [0.4] vs. 0.3 [0.5], p = 0.009, respectively). During follow-up, 8 and 78 patients with and without diabetes died, respectively (logarithmic rank p = 0.187). Conclusions: Histopathology of the ascending aorta during ATAAD reveals distinctive severity of aortic wall atherosclerosis in patients with diabetes mellitus versus those without. The degree of atherosclerosis assessed postoperatively is associated with the extent of surgical procedure in many patients and may guide follow-up protocol. Full article

Background: Aortic valve infective endocarditis (IE) complicated by an aortic root abscess is a challenging problem that leads to increased morbidity and mortality. Aortic root repair or replacement are two potential treatment options. We aimed to compare patients undergoing aortic root repair or replacement with short- and mid-term outcomes. Methods: Consecutive patients with active aortic valve IE complicated by aortic root abscess undergoing cardiac surgery from January 2012 to January 2022 were included. Patients receiving aortic root repair were compared to patients undergoing aortic root replacement. Endpoints included overall mortality, incidence of recurrent IE and re-intervention during a two-year follow-up period. Inverse propensity weighting was employed to adjust for confounders. Results: Seventy-three patients with aortic valve IE with root abscess underwent surgical therapy. Fifty-six patients received aortic root repair and seventeen patients underwent aortic root replacement. Patients undergoing root replacement had significantly higher surgical risk (EuroSCORE II: 9 versus 19, p = 0.02) and extended disease (circumferential annular abscess: 9% versus 41%, p < 0.01). Inverse propensity weighted analysis revealed no relationship between surgical strategy and outcome. Weighted regression analysis revealed EuroSCORE II and disease extension as significant predictors of 30-day and 2-year mortality. Conclusions: In patients with aortic valve IE with root abscess, root repair is mostly performed in lower-risk patients with limited disease extension. Short- and mid-term mortality, recurrent endocarditis and reintervention were comparable between surgical strategies during follow-up. Surgical risk and disease extension, rather than surgical strategy, seem to be significant predictors of short- and mid-term mortality. Full article

Objectives: Several conditions associated with type A aortic dissection may require preoperative invasive mechanical ventilation (IMV). The current literature lacks data on this subset of patients’ prevalence and postoperative outcomes. This study aims to investigate this unexplored issue in a multicenter European registry. Methods: Data from 3735 patients included in the European Registry of Type A Aortic Dissection (ERTAAD) were the subject of this analysis. Bootstrapped Least Absolute Shrinkage and Selection Operator (LASSO) logistic regression was performed for variable selection to identify key predictors of hospital death. In the second step, a multilevel multivariable logistic regression (MMLR) was carried out, given the clustered structure of the data. Results: A total of 346 (9.3%) out of 3735 patients required preoperative IMV. Compared to the non-IMV patients, patients requiring IMV had a significantly higher rate of organ malperfusion (52% vs. 35%, p < 0.001) and a higher proportion of tears in the aortic root (p = 0.048). The in-hospital mortality rate among IMV patients was 38% vs. 15% in non-IMV patients (p < 0.001), without a difference in post-discharge survival (p = 0.84). At the MMLR, patients who required IMV had 135% higher odds of in-hospital death compared to the remaining patients. IMV yielded the second highest odds in the prediction model for in-hospital mortality (OR 2.13, CI 1.60 to 2.85, p < 0.001). Among IMV patients, the extension of surgery to the aortic arch was significantly associated with increased in-hospital mortality (p < 0.001, OR 2.98). In multivariable analysis, preoperative IMV was independently associated with increased odds of in-hospital mortality. Conclusions: The need for invasive mechanical ventilation before surgical repair for type A aortic dissection is not infrequent. In this subpopulation, the in-hospital mortality rate was twofold compared to patients who did not require IMV. The awareness of the preoperative risk profile and outcomes of this subset of patients should urge surgeons to tailor the surgical strategy more appropriately to improve the immediate postoperative results. Full article

Objective: Over the last ten years, aortic surgery has transitioned from a high-risk procedure to a well-established operation, offering favorable outcomes and survival when performed by experienced hands. Advances in surgical techniques and evolving technologies allow treatment of older and more complex patients with reoperations. However, outcome data are limited. This study aims to identify risk factors for adverse outcomes after reoperation on the aortic root. Methods: This retrospective study included patients who received aortic root reoperation from 1999 to 2023 in a high-volume center, with a history of previous surgery on the thoracic aorta or aortic valve. Patients under the age of 18 or those with transcatheter aortic valve implantation as an index procedure were excluded. Results: A total of 192 patients were analyzed. Mean age was 57 ± 13 years, and 77.6% were men. The main procedure was Bentall (88.5%). An elective operation was performed in 54.7% of the patients. The mean time between the index operation and reoperation was 8.61 (3.01–16.05) years. Mortality at 30 days was 13%. Survival rates at one, five, and ten years were 84%, 81%, and 71%, respectively. Female gender, non-elective surgery, concomitant procedures, and combined procedures on the aortic root and arch were associated with worse survival. In the Cox regression, age (HR = 3.98, p < 0.01), EuroSCORE II (HR = 1.46, p < 0.01), concomitant procedures at reoperation (HR = 2.53, p = 0.01), prolonged cardiopulmonary bypass time (HR = 1.01, p < 0.01), bleeding complications (HR = 6.11, p < 0.01), and need for temporary mechanical circulatory support (HR = 4.86, p = 0.01) were significantly associated with a higher mortality. Analysis of the receiver operating characteristic curve revealed that age > 60 years at reoperation is a strong predictor for poor outcomes (AUC = 0.712, p < 0.01). Conclusions: Mortality following aortic root reoperation is primarily driven by baseline patient risk and perioperative complications. Reduced survival was observed in patients over 60 years of age, females, those having non-elective surgery, combined root and arch operations, and procedures with additional concomitant operations. Bleeding events, the use of temporary mechanical circulatory support, and concomitant interventions at reoperation emerged as independent predictors of mortality. Full article

Background: Transcatheter aortic valve replacement (TAVR) is at the forefront of structural heart programs all over the world. With a growing number of TAVR procedures in lower-risk and younger patients, acute and chronic complications require decisive treatment. The aim of the present study is to retrospectively analyze the efficacy of surgical bailout strategies in case of complications from TAVR that had been performed in the highest-volume center in Italy over the past ten years. Methods: Acute complications were defined as events occurring in the first 24 h after surgery, while chronic complications were defined as events occurring within the first year post-implant. We retrospectively analyzed the 2731 patients who had undergone TAVR at our institution from January 2015 to August 2024. Results: A total of 21 patients were included, with a median age of 78 years (IQR 11y). The majority of patients underwent TAVR with a self-expanding prosthesis (76%). A total of 11 patients (52%) presented acute complications, of which the most common were aortic dissection (n = 4 [19%]) followed by left ventricular perforation (n = 3 [14%]). The most common chronic complication was early endocarditis (n = 5 [24%]). The most common bailout strategy was aortic valve replacement (AVR), which was sufficient in 10 patients (48%), followed by complete root replacement (n = 4 [19%]). In-hospital mortality was higher in acute compared with chronic complications albeit not statistically significant (n = 4 [36%] vs. n = 2 [20%], p = 0.64), highlighting the very high risk of all these surgeries. Conclusions: Bailout and post-TAVR surgery are critical issues, with overall acceptable yet significant mortality considering the very high risk of these procedures. In our experience, half of the overall complications cannot be resolved with a simple explant and subsequent valve replacement, thereby underlining the importance of skilled cardiothoracic surgery teams on site to address complex issues such as ventricular perforation and emergency aortic/root replacement. Full article

Marfan syndrome (MFS) is an inherited connective tissue disorder, with aortic root aneurysm and/or dissection being the most severe and life-threatening complication. These conditions have been linked to pathogenic variants in the FBN1 gene and dysregulated TGFβ signaling. Our objective was to evaluate the mRNA expression of FBN1, TGFBR1, TGFBR2, and TGFB2 in aortic tissue from MFS patients undergoing surgery for aortic dilation. This prospective study (2014–2023) included 20 MFS patients diagnosed according to the 2010 Ghent criteria, who underwent surgery for aneurysm or dissection based on Heart Team recommendations, along with 20 non-MFS controls. RNA was extracted, and mRNA levels were quantified using RT-qPCR. Patients with dissection showed significantly higher FBN1 mRNA levels [79 (48.1–110.1)] compared to controls [37.2 (25.1–79)] (p = 0.03). Conversely, TGFB2 expression was significantly lower in MFS patients [12.17 (6.54–24.70)] than in controls [44.29 (25.85–85.36)] (p = 0.029). A positive correlation was observed between higher FBN1 expression and a larger sinotubular junction diameter (r = 0.42, p = 0.07), while increased FBN1 expression was particularly evident in MFS patients with dissection. Additionally, TGFB2 expression showed an inverse correlation with ascending aortic diameter (r = 0.53, p = 0.01). In aortic tissue, we found decreased TGFB2 and receptor levels alongside increased FBN1 mRNA levels. These molecular alterations may reflect compensatory mechanisms in response to tissue damage caused by mechanical stress, leading to dysregulation of physiological signaling pathways and ultimately contributing to aortic dilation in MFS. Full article

Background/Objectives: We reviewed data from the Western Danish Heart Registry (WDHR), which collects mandatory information on heart surgeries in Western Denmark, to validate cases with aortic root replacement (ARR) and assess the validity of registered data for all recorded cases. Methods: Patients registered in the WDHR with Danish Health Care Classification System (SKS) codes KFC and KFM from January 1999 to April 2022 were reviewed using electronic medical records. All patients who underwent ARR were included, and clinical data from the WDHR were adjudicated against electronic medical records. Results: A total of 847 cases with ARR were identified. Missing values averaged 12.0% in baseline variables (range: 3.2–22.1%), 7.3% in EuroSCORE II variables (range: 0.8–48.9%), and 5.5% in postoperative outcome variables (range: 4.1–8.1%). After adjudication, unrecovered data averaged 6.5% for baseline variables (range: 0.1–11.7%), 5.3% for EuroSCORE II variables (range: 0–32.5%), and 0.5% for postoperative outcomes (range: 0–0.8%). Missing data among EuroSCORE II were lower from 2012 and beyond (2.9% (range: 0.6–14.3%)). The median EuroSCORE II according to the WDHR was 6.2% (95% confidence interval 1.4–6.3) and after adjudication 10.7% (95% confidence interval 3.3–13.3). The positive predictive value for arrhythmia, central nervous damage, dialysis, reoperation for bleeding, and reoperation for ischemia exceeded 95%. Conclusions: The WDHR demonstrated overall value for clinical epidemiological research in ARR, but cases require validation to differentiate between procedures due to insufficient coding, while adjudication resulted in significantly higher data completeness for the majority of the variables. Full article

Background: Valve-sparing root replacement surgery is an alternative strategy for patients with aortic regurgitation with or without aortic root enlargement. A detailed understanding of the mechanisms of regurgitation and the morphology of the aortic root would be beneficial for predicting the feasibility and success of valve-sparing surgery. This is an exploratory study of the measurement of geometric height in 3D transesophageal echocardiography as a predictor of valve-sparing root replacement for aortic regurgitation. Methods: Transesophageal echocardiographic findings and long-term outcomes were compared in 124 patients undergoing either valve-sparing root replacement (VSRR group) or composite valve graft replacement (Bentall group) from September 2014 to March 2019. Results: The VSRR group was younger and had better left ventricular function than the Bentall group. Three-dimensional transesophageal echocardiography showed that geometric height was significantly larger in the VSRR group. In receiver-operating curve analysis, the cutoff values of geometric height for the feasibility of valve-sparing surgery were 15.9 mm and 19.8 mm in the tricuspid and bicuspid aortic valve, respectively. The overall survival was 98.6% and the freedom from reoperation rate was 89.7% at 5 years in the VSRR group. Conclusions: Appropriate patient selection and adequate GH may contribute to the success of VSSR and improve long-term outcomes. Full article

Congenitally corrected transposition of the great arteries (ccTGA) is an infrequent and complex congenital malformation, which accounts for approximately 0.5% of all congenital heart defects. This defect is characterized by both atrioventricular and ventriculoarterial discordance, with the right atrium connected to the morphological left ventricle (LV), ejecting blood into the pulmonary artery, while the left atrium is connected to the morphological right ventricle (RV), ejecting blood into the aorta. Due to this double discordance, the blood flow is physiologically normal. Most patients have coexisting cardiac abnormalities that require further treatment. Untreated natural course is often associated with progressive failure of the systemic right ventricle (RV), tricuspid valve (TV) regurgitation, arrhythmia, and sudden cardiac death, which occurs in approximately 50% of patients below the age of 40. Some patients do not require surgical intervention, but most undergo physiological repair leaving the right ventricle in the systemic position, anatomical surgery which restores the left ventricle as the systemic ventricle, or univentricular palliation. Various types of anatomic repair have been proposed for the correction of double discordance. They combine an atrial switch (Senning or Mustard procedure) with either an arterial switch operation (ASO) as a double-switch operation or, in the cases of relevant left ventricular outflow tract obstruction (LVOTO) and ventricular septal defect (VSD), intra-ventricular rerouting by a Rastelli procedure. More recently implemented procedures, variations of aortic root translocations such as the Nikaidoh or the half-turned truncal switch/en bloc rotation, improve left ventricular outflow tract (LVOT) geometry and supposedly prevent the recurrence of LVOTO. Anatomic repair for congenitally corrected ccTGA has been shown to enable patients to survive into adulthood. Full article

The Bicuspid Aortic Valve (BAV) is the most common congenital anomaly in adults, with a global incidence of 1.3%. Despite being well documented, BAV presents significant clinical challenges due to its phenotypic heterogeneity, diverse clinical manifestations, and variable outcomes. Pathophysiologically, BAV differs from tricuspid valves in calcification patterns and hemodynamic effects, leading to increased shear stress and aortic root dilatation, while it is influenced by genetic and hemodynamic factors. This is why therapeutically, BAV presents challenges for both surgical and transcatheter interventions, with surgical approaches being traditionally preferred, especially when aortopathy is present. However, transcatheter aortic valve implantation (TAVI) has emerged as a viable option, with studies showing comparable outcomes to surgery in selected patients, while advancements in TAVI and a better understanding of BAV’s genetic and pathophysiological nuances are expanding treatment options. The choice between mechanical and bioprosthetic valves also presents considerations, particularly regarding long-term durability and the need for anticoagulation. Future research should focus on long-term registries and genetic studies to refine therapeutic strategies and improve patient outcomes. This review aims to evaluate current approaches in the surgical and interventional management of BAV, focusing on its anatomy, pathogenesis, pathophysiology, and therapeutic strategies. Full article

Objective: Acute aortic dissection is a rare but frequently fatal aortic catastrophe with high morbidity and mortality. Especially in pregnant patients, acute dissection is often misdiagnosed putting two lives on the line. Due to its scarcity, only case reports have been reported. The aim of this study is to analyze the time of aortic dissection during the course of pregnancy and the outcome of emergency surgery in pregnant women with and without hereditary connective tissue disorder. Methods: We retrospectively reviewed all acute aortic dissections (type A and B) who underwent emergency aortic surgery at our institution between 1994 and 2022 and identified 13 patients with acute aortic dissection during pregnancy or directly postpartum. Mann–Whitney U and Fisher’s exact tests were used for statistical analysis. Results: Of the 13 included patients, 5 had a genetic syndrome. These patients were significantly younger at the time of dissection and at an earlier stage of pregnancy (second trimester). Even though operative and in-house mortality was zero, we lost one patient on postoperative day 14 due to rupture of the aortic root after transfer to another hospital. Survival of neonates was 77% including two aborted pregnancies. Conclusions: Surgical treatment of acute aortic dissection during pregnancy can be performed with excellent operative mortality for the mothers and satisfying survival of their neonates. In patients with genetic syndrome, dissection occurs during the early second trimester, whereas non-syndromic patients experience acute dissection in the late third trimester. Long-term follow-up is essential for timely re-intervention, if needed. Full article